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How do you do this? How many TAAs have you seen? In what percentage of the times that you thought you saw a TAA were you right? In what percentage were you wrong? How many patients have you evaluated who you didn't think had a TAA? How often were you right? How often were you wrong? How do you feel this compares to assessment by a ER fellow? IM / Cardiology? Can you beat U/S or mediastinial changes on CXR? How do you compare to thoracic CT? What makes you think that you can do this better than everyone else? With less education, and less technology? Physicians in the ED with a million times more experience, education and training time, and better technology miss these on a regular basis. Has it? Perhaps it has, I don't know. Or has an increase in education made us more aware of diagnostic uncertainty? Are we better able to understand the limitations and benefits of the technology available to us? I can't. I can identify clear presentations of any of these conditions, but I can't always differentiate them in a complex setting. And perhaps it's because I'm too reliant on technology, and that my physical examination and history taking skills are inferior to yours. Or possibly it's because I know that each of these diseases can occur in the presence of the other. Perhaps I also know that physical exam has limited diagnostic utility for either condition. Perhaps it's because I know that they can look almost identical in early presentations. Or perhaps it's because I know that even far better trained and educated ER physicians routinely misdiagnose CHF and pneumonia patients because even with better technology, e.g. labs, U/S, CXR, cultures, there remains a lot of diagnostic uncertainty. So, just so I understand your position -- you're a paramedic (like me). You've had (maybe) 3 years of education specific to "medicine". You've worked in an ambulance, or perhaps a fixed wing or helicopter for a number of years. And now you feel that you can better diagnose disease states than a physician with a 4-year BSc, 4-year MD, 5 year ER residency, and years of clinical practice. A physician who probably sees more patients in a shift than a medic sees in a tour, who's had extensive rotations through every medical specialty (not just 2 weeks in the OR, 2 weeks in case room, a couple of weeks in CCU, and a couple of days in NICU), and has imaging technology and the ability to get chemistry / microbiology. And you think that you're better than that? Because if you are, we should start collecting money. All of us. And we should send you to Harvard or Yale, or Columbia. you can go talk to the Dean of Medicine there, and show them what they're doing wrong. We can shorten physician training down to 3 years, sell of all the CT machines, get rid of the U/S, put all the RTs on welfare (sorry guys!), close all the medical schools, and you can show them how it's done better. I'm not going to get into the quagmire that is beta-agonists in CHF. Don't have the energy. Am J Emerg Med. 2010 Oct;28(8):862-5. Epub 2010 Mar 25. A multicenter analysis of the ED diagnosis of pneumonia. Chandra A, Nicks B, Maniago E, Nouh A, Limkakeng A. Source Department of Emergency Medicine - Duke University Medical Center Durham, NC 27710, USA. abhinav.chandra@duke.edu Abstract OBJECTIVES: The objective of this study was to describe the prevalence of pneumonia-like signs and symptoms in patients admitted from the emergency department (ED) with a diagnosis of community acquired pneumonia (CAP) but subsequently discharged from the hospital with a nonpneumonia diagnosis. METHODS: A retrospective, structured, chart review of ED patients with CAP at 3 academic hospitals was performed by trained extractors on all adult patients admitted for CAP. Demographic data, Pneumonia Patient Outcomes Research Team scores, and discharge diagnosis data (International Classification of Diseases, Ninth Revision [iCD-9] codes) were extracted using a predetermined case report form. RESULTS: A total of 800 patients were admitted from the ED with a diagnosis of CAP from the 3 hospitals, and 219 (27.3%; 95% confidence interval [CI], 24-31) ultimately had a nonpneumonia diagnosis upon discharge. Characteristics of this group included a mean age of 62.6 years, 50% female, and a history of congestive heart failure (CHF) (14%) or cancer (12%). After excluding patients with missing data, 123 patients (65%) had an abnormal chest x-ray, and 13% had abnormal oxygen saturation. Cough, sputum production, fever, tachypnea, or leukocytosis were present in 91.5% of this cohort, and 63.8% had at least 2 of these findings. Twenty alternate ICD-9s were identified, including non-CAP pulmonary disease (18%; 95% CI, 13-24), renal disease (16%; 95% CI, 13-19), other infections (9%; 95% CI, 7-11), cardiovascular diseases (3%; 95% CI, 2-4), and other miscellaneous diagnosis (28%; 95% CI, 25-31). CONCLUSIONS: Our data suggest that the ED diagnosis of CAP frequently differs from the discharge diagnosis. This may be due to the fact that a diagnosis of CAP relies on a combination of potentially nonspecific clinical and radiographic features. New diagnostic approaches and tools with better specificity are needed to improve ED diagnosis of CAP. Copyright © 2010 Elsevier Inc. All rights reserved. PMID: 20887906 [PubMed - indexed for MEDLINE]

It's threads like this that should be compulsory reading for every skill-monkey who thinks that we are overeducated in the first place. Every day I wake up worrying that I don't know enough to do my job well, and then I confirm that by reading this sort of thread!

Ah, here is the problem. You don't think you are an awesome medic nor hear the voice of god. You truly think you are god. Explains alot. Thanks for playing, your tin foil hat is waiting.

If you are doing this to present an argument to your medical director, I recommend you tread very lightly. A lot of the latest research looks bad for prehospital RSI, and intubation in general. Is there any reason they are using versed over etomidate? Etomidate is quicker on/quicker off if things go bad. From personal experience, it works much better for sedation anyway. If you adequately sedate there is no reason to complicate things by adding more meds such as an analgesic. I'm a simple person and like to keep things simple. If someone is being RSI'd they are sick to begin with. You are now going to throw a bunch of meds at them. If they deteriorate, how will you be able to decide if it is from there underlying disease versus medication issues? I'm also not a big fan of pharmacologically assisted intubation. You either go all in, or not at all (yes, I realize there are exception, but as a general rule). If they are going to have you sedate and quasi-paralyze, why not just go all the way and make sure it is done correctly to optimize your chances of success? In that case, the sux would be a much better option as it is quick on/quick off. There are a few instances where it may not be the best option but more often it will be fine.

Wow, did you seriously just advocate for pushing narcan just because someone is unconscious? You just lost any thread of credibility you ever had right there. The coma cocktail when out of style with Johnny and Roy. Seriously, when I started EMS in 1992 in a far from progressive system they were talking about the coma cocktail as, "That crazy stuff we did years ago." If I was your medical director, I would pull your card right there if you ever gave a coma cocktail. No, I have never had a significant discrepancy between my glucometer and my labs, when they were used properly. A few points here and there, but nothing that would change management. I've seen a few operator errors that have caused a discrepancy, but the values they obtained did not make sense so a repeat was always done. When something doesn't make sense, you need to recheck. You can do harm in stroke pts by putting them into a hyperglycemic state. http://stroke.ahajournals.org/content/35/2/363.full As for your ASA agruement, have you ever heard of a NSTEMI? systemet has addressed this pretty well, so I won't do it again. Keep in mind that ASA is not without it's complications. Do you think it would be a good idea to give a drug to someone that prevents platelet aggregation who has a dissection? I'll let you think it through.

I guess I missed the part where I should WANT to be someone else. ANYONE else, for that matter. That type of mentality makes no sense to me. How about being the best person YOU can be and not worrying about being someone or something you are not? Stop celebrating victimhood, crochity. It's not noble, you don't get points for being a martyr, nor does it ever help you get ahead in life. I am who I am- for better or worse. If I have flaws or problems I work to change them and improve myself. I think it's ridiculous to spend your life wanting to be someone else. Envy and jealousy are very ugly and nonproductive traits. Get off the damn pity pot already. That act has long since gotten stale and old.

To be honest am not sure if i was responding to you or not. Mainly just expressing an idea. I guess I was thinking about the guys who treat their patients like they were a machanical part that needs to be fixed. The guys that don't respect their patients or their dignity don't deserve the job. Doing the job well includes caring as well. Not at all. I think we are on the same page. I was on a MVA with a 15 yr old DOA in the back seat. The dad shows up on the scene asking about his son and wanting to see him. I had gone to high school with the dad but did not know the kid. We sat on the sidewalk and shared a cry then I walked over to see the boy. That was a turning point for me. I decided to care and to care deeply. I don't think caring is baggage it is more like a privilege. .When I mentioned dehumanizing I wasn't implying that the science can be ignored. I have to constantly work not to have tunnel vision toward the condition and ignore the person. Yea, thare is a time to ignore their screams (or thank God they are screaming) as well a time when I know I am about to inflict pain to give them the best chance I can at survival. There is also a time for a soft touch and a kind word. Most of our patients deserve both. I had never really considered calls in those terms but I like it. We can either win or loose against the condititions. It will be food for thought on my next call. I guess every call is a fight, against nature, trauma, time. We either win or loose. [ We all express love in different ways, protecting is one of them .... loving patients will make a good medic great.

They dont tell you that you might not get past "A".....................

Alternatively, some of us don't believe in compromising the Constitution in the name of fear mongering.